Online Health Chat with Paul Bryson, MD
April 13, 2015
Although most voice disorders are not life-threatening, maintaining overall good health through healthy habits is critical. If you do have a voice disorder, there are a variety of treatment options available, from medical treatment to surgical procedures to functional voice therapy. Voice problems can start from something as common as hoarseness or can be a more complex issue such as vocal cord paralysis or a swallowing disorder.
Other disorders of the voice involve problems with pitch, loudness and quality. Symptoms of a voice problem include such things as:
- discomfort when talking or singing
- loss of singing control and effort/strain
Take this opportunity to learn more about voice disorders and caring for your voice, as well as to have your questions answered by voice specialist Dr. Paul Bryson from the Cleveland Clinic.
About the Speaker
Paul Bryson, MD, director of The Voice Center and head of the Section of Laryngology, is a board-certified otolaryngologist in Cleveland Clinic’s Head & Neck Institute. He earned his medical degree from University of Pittsburgh School of Medicine, Pittsburgh, PA, and completed his residency at the University of North Carolina Hospitals, Chapel Hill, NC. He also completed a fellowship at Massachusetts General Hospital Center for Laryngeal Surgery/Voice Rehabilitation.
Dr. Bryson is a member of several professional societies including: The American Academy of Otolaryngology-Head and Neck Surgery (AAO), The Triological Society, the American College of Surgeons, and the Voice Foundation. He serves as a committee member of the airway and swallowing committee of The AAO.
Dr. Bryson’s specialty interests encompass the full range of voice and oropharyngeal swallowing disorders including: medical and surgical care of the professional/performer's voice, benign vocal cord lesions such as nodules or polyps, vocal cord dysplasia or early cancer, vocal cord papilloma, vocal cord paralysis, neurolaryngological problems such as spasmodic dysphonia, Zenker's diverticulum and cricopharyngeal dysphagia.
Let’s Chat About Voice Conditions
Moderator: Welcome to our chat about Voice Conditionswith Cleveland Clinic specialist Dr. Paul Bryson. Thank you, Dr. Bryson, for taking the time to be with us to share your expertise and answer our questions.
Let’s get started with our questions.
Need to Know
whitej: What are some common types of voice disorders?
Paul_Bryson,_MD: This is a very broad question. Common voice disorders would include laryngitis and vocal cord lesions such as nodules and polyps. Other voice disorders would be the result of vocal cord paralysis or weakness of the vocal cords. This can sometimes be the result of surgeries or a consequence of aging.
Heather30: What can people do to prevent damaging their voices?
Paul_Bryson,_MD: This typically involves common sense. I try to have people not frequently push their voices to talk over background noise. Frequent screaming and yelling should be avoided. If you feel that your voice is becoming hoarse, voice rest or reduced vocal use is recommended. If you have hoarseness lasting longer than two weeks, it is reasonable to have your vocal cords examined.
Rads: I'm a 67-year-old male with left side facial paralysis caused by an acoustic neuroma removed 37 years ago. The operation was nine hours in duration with intubation for anesthesia. A subsequent 12-7 hypoglossal-to-facial nerve transplant done 35 years ago possibly resulted in severing or damage of the recurrent laryngeal nerve. Both operations left me plagued by a weak voice and frequent hoarseness. An examination of my vocal folds indicated no irregularity, and I have no acid reflux. I am now required to do a lot of public speaking with a gravelly voice, and I am unable to project for long periods of time. Any help would be appreciated.
Paul_Bryson,_MD: If there is vocal cord paralysis, your vocal cords are not coming together. It is possible that you would be a candidate for a procedure to try to strengthen the voice. I cannot know for sure unless I can examine your vocal cords to see how they come together.
Ridgeline: My name is Bill. Regarding Parkinson's disease and recommendations for strengthening the voice, what is the solution for a voice that turns into a whisper in the evening?
Paul_Bryson,_MD: There is a special type of voice therapy for Parkinson's disease patients called Lee Silverman Voice Therapy (LSVT) to improve the loudness. This is an intensive type of voice therapy. If this does not help you meet your needs, I would look at the vocal cord closure pattern. I will sometimes offer augmentation procedures to try to help with this.
SmartMart: What can I do for a wobbly, scratchy, soft voice? I am 80 years old. Is this normal?
Paul_Bryson,_MD: This could be from normal aging of the vocal cords. Sometimes, the vocal cords become thin and atrophic with aging, but not always. The wobbly aspect of the voice could be vocal tremor, but we would have to listen to the voice and examine the vocal cords to know more specifically.
fjpor: I have lost my singing voice, and when I try to speak to a group, I must use amplification. A trip to the doctor revealed that my vocal cords were not closing properly and that this was not a surprise condition for a person "my age." That was about two years ago and I'm 76 now. Trying to speak loudly enough to be heard actually, by the end of the day, makes my throat hurt. My sister has similar problems and was told her vocal cords are bowed. There is a procedure to help but insurance will not pay for it because, it appears, neither of us is in a "career" where our voice is our instrument. Do you have any suggestions? I did have a period of time when I had serious erosion of the esophagus and some ulcers caused by acid reflux so I am assuming that didn't help with this.
Paul_Bryson,_MD: Based on your story, these do sound like age-related changes to the vocal cords. I usually start with referral to a speech pathologist for vocal cord strengthening exercises. If this does not help and there is evidence of incomplete vocal cord closure, I will talk with the patient about augmentation procedures to help with voice rehabilitation. I have not had problems with health insurance approval for this, so I am not certain what the issue is. I would recommend being seen in a comprehensive voice center if possible.
Situation Side Effects
BTroyer: Can you talk a little bit about the effect thyroid nodules can have on the voice, if any?
Paul_Bryson,_MD: Generally speaking, I do not feel that thyroid nodules affect the voice. Occasionally, conditions that cause thyroiditis will sometimes cause pain and discomfort, which can secondarily affect the voice, but this is uncommon.
Jack_in_Florida: Is there any hope for a paralyzed vocal cord due to a botched thyroidectomy? I did vocal function exercises, but still have a weak voice.
Paul_Bryson,_MD: There absolutely is hope for voice rehabilitation after a complication of thyroid surgery. This is one of the most common procedures that we perform at The Voice Center. It is called medialization laryngoplasty, and people typically do very well with this with significant improvement in their voice. Not all ear, nose and throat doctors do this operation, and I would recommend seeing an experience surgeon at a large medical center like the Cleveland Clinic.
mimsy111: I've been put on pantoprazole 40 mg two times a day for three months for silent reflux hoarseness. When I stop taking it, what will prevent my hoarseness from returning? I follow an acid-reducing diet faithfully.
Paul_Bryson,_MD: It is hard to say without seeing how your vocal cords looked and vibrated before you were put on reflux medication. Oftentimes, medication is used in conjunction with lifestyle and dietary modification. I would typically re-evaluate the appearance of the larynx at the conclusion of the medical trial. I would also determine if there is any role for voice therapy with an experienced speech pathologist. Sometimes, reflux can be overtreated, but it would really depend on each individual patient's symptoms and endoscopic findings.
isingbari: I have been taking Advair® for bronchial asthma for several years. My voice is rough and sounds gravely. I am a singer. Is there anything I can do to avoid this side effect short of discontinuing the Advair? Other medications have not helped my asthma.
Paul_Bryson,_MD: This can be a difficult problem. I would need to examine the appearance of your larynx to see if there is, indeed, irritation or any evidence of a superficial fungal infection. I would also make sure that you are clearing and rinsing your throat well after using your Advair. I typically have patient's drink and eat after using their inhalers. I would also push your pulmonologist to try other treatments/inhalers if this is a chronic problem. I would also look at these issues in the context of your everyday vocal demands.
Diagnosis and Treatment
mimsy111: Should a person with silent reflux and hoarseness be seeing by an ENT or a gastroenterologist?
Paul_Bryson,_MD: I think, typically, ENT doctors are more comfortable with this diagnosis. There are some gastroenterologists who do not necessarily believe in silent reflux. The ENT doctor will be able to directly visualize the throat and vocal cords in the office more easily than the GI doctors.
C64890: I keep losing my voice every quarter. It usually kicks off with bronchitis in November, and every three months I get laryngitis. I have been to the ENT numerous times with no real results and no nodules detected. I can even feel when it is coming on. I do snore at night, and phlegm builds up in the back of my throat overnight. I have GERD under control. What keeps causing this and what can I do the minute I feel the laryngitis starting? How do I know if I don't have spasmodic dysphonia?
Paul_Bryson,_MD: It is hard to say exactly what is going on here. Sometimes with bronchitis, people have significant coughing and throat clearing, which can cause inflammation of the vocal cords and subsequent hoarseness. When this happens and you feel your voice is getting bad, I would recommend voice rest and hydration. If it persists, I would recommend seeing an ear, nose and throat doctor who has some interest and sophistication with voice issues. The Voice Center has high-resolution endoscopy equipment that will often allow us to see changes on the vocal cords more easily.
Spasmodic dysphonia is a neurologic type of voice disorder that is a dystonia of the vocal cord muscles. This diagnosis is made by an experienced voice specialist. This could be a laryngologist or a speech-language pathologist who specializes in voice disorders.
Tiffany: If a patient is complaining of hoarseness, how would you diagnose and treat it? Why is voice therapy recommended for hoarseness? If it is recommended, what does voice therapy entail?
Paul_Bryson,_MD: Typically, diagnosis involves a complete history and physical examination including laryngoscopy with video stroboscopy. This allows for complete evaluation of the biomechanics of the vocal cords. Voice therapy is sometimes recommended for hoarseness if the hoarseness appears to be secondary to vocal overuse or other maladaptive vocal behaviors. Voice therapy typically entails a number of strategies including vocal hygiene, breath support and various exercises to address resonance and voice placement. An experienced speech pathologist who does a lot of voice therapy is your best bet.
siggy: I recently read about an experimental vocal cord injection technique to help patients with spastic dysphonia. Does it work?
Paul_Bryson,_MD: I am uncertain of what this experimental vocal cord injection entails. Currently for spasmodic dysphonia, the most common treatment is vocal cord BOTOX® injections, which have been the treatment of choice for many years.
Disorders and Complications
Valpat: I had idiopathic left true vocal cord paralysis several years ago and recovered spontaneously after about five months. Having had this once, are my vocal cords more susceptible to further issues like a reoccurrence, difficulty with intubation during general anesthesia, or spasms from allergies or reflux? Thank you.
Paul_Bryson,_MD: There is a small risk and you could have another idiopathic vocal cord paralysis, but this is unlikely. I would not suspect that you would have difficulty with intubation from a unilateral vocal cord paralysis. There is also no documented risk of having vocal cord spasms from allergies or reflux in patients who have had prior vocal cord paralysis.
Nanat426: I have systemic sarcoidosis. My voice gets hoarse very frequently along with times where swallowing is difficult. Could the hoarseness be associated with the sarcoid or something else? (The hoarseness has been going on for many years.) I am on Nexium® to prevent any additional problems with acid going into my lungs. Very seldom do I have acid reflux. Thanks so much.
Paul_Bryson,_MD: Sarcoidosis can affect many organ systems as you are well aware. I have seen sarcoidosis in different areas of the larynx, and this could certainly result in hoarseness. Given the wide spectrum of presentation, I would recommend examination to see the impact of the sarcoidosis in your larynx.
retro: What causes vocal cord paralysis?
Paul_Bryson,_MD: There are many causes of vocal cord paralysis. The most common is a complication from another surgery such as thyroid surgery, anterior spine surgery, carotid endarterectomy or traumatic intubation. There are some times when we cannot determine the cause, and this is called idiopathic.
sleepytime: I have a paralyzed vocal cord. How long should it take to recover my voice?
Paul_Bryson,_MD: It really depends on the etiology of the vocal cord paralysis. I typically give the vocal cord 10 to 12 months to achieve spontaneous recovery. During this time, I will offer patients temporary vocal cord injections to help them with their voice. Additionally, I will sometimes obtain a laryngeal EMG, which can tell me if the nerve appears to be recovering.
JasanKnot: My doctor tells me I have a growth on my vocal cord called a "papilloma." He advises surgery, but I don't want surgery. What do you advise? Also, what is the difference between a papilloma and a polyp?
Paul_Bryson,_MD: A vocal cord papilloma is typically from human papilloma virus, which is an infection that can affect the vocal cords. There is a wide spectrum of severity, but unfortunately these lesions can grow and frequently recur at varying intervals.
Surgery for this is not unreasonable. If it is not affecting your voice, you could certainly opt for observation, but I would be prepared for possible surgery in the future should your voice become affected.
robertz: I was told that I had two growths called "polyps" on my vocal cords. I tried an inhaler, then pills, shots, gargles, voice rest and even bed rest, but all these things failed. What do you recommend?
Paul_Bryson,_MD: I would typically have to look at the lesions on your vocal cords to make a definitive recommendation; however, if the lesions on your vocal cords are affecting your voice and do not heal with conservative measures, then surgery is a possibility.
a910: What are vocal cord nodules and polyps? What treatments are available for nodules and polyps?
Paul_Bryson,_MD: Vocal cord nodules are callus-like growths on the vocal cords that develop slowly over time from voice overuse or poor vocal technique. The treatment for these is typically voice therapy with surgery as a last resort. A vocal cord polyp is a general term for a polyp-like lesion on the vocal cords that can develop from vocal cord trauma or smoking. Voice therapy is typically less successful for these lesions, and they may ultimately require surgery.
genodoc: I have to "clear my throat" frequently. It drives my wife nuts. I have had an ENT exam = WNL. Do you have any ideas to correct this? I think it's allergy vs. dry throat mucous membranes.
Paul_Bryson,_MD: This is a very common complaint and sometimes difficult to treat and explain. I will try a number of things including empiric treatment for reflux, treatment of suspected allergies, and I will even look at a patient's medications to see if there is any medication that would have this is as a side effect. There are even a small number of patients where I will have them see the speech pathologist to see if this is a habit that needs behavioral intervention to stop.
Moderator: That is all the time we have for questions today. Thank you, Paul Bryson MD, for taking time to increase our knowledge about conditions that can affect our voice. On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative.
Paul_Bryson,_MD: I would like to thank everyone for their interesting and thoughtful questions. I appreciate the opportunity to interact with you in this format. If there is anything that we can do further, please let us know. We would certainly be happy to see you at the Cleveland Clinic Voice Center. Sincerely, Paul Bryson
To make an appointment with Paul Bryson, MD, or any of the other voice specialists in the Head & Neck Institute, please call 216.445.TALK or toll-free at 800.223.2273, ext. 58255, or visit us online at http://my.clevelandclinic.org/services/head-neck.
For More Information
Cleveland Clinic Head & Neck Institute
Physicians in Cleveland Clinic’s Head & Neck Institute (HNI) specialize in voice disorders, sleep disorders, head and neck cancer, laryngology and tracheal reconstruction, nasal and sinus disorders, otology, audiology and vestibular and balance disorders.
Cleveland Clinic’s ear, nose and throat program is top-ranked in Ohio and among the top 10 in the nation by U.S. News & World Report’s Best Hospitals Survey.
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